CMS/EIP Fiscal Report Center: 10
Services beginning 04/01/2009 ending 06/30/2009 Date of Report:08/25/2009 Page: 1
Payclass Filters:TPIN
Eligibility Filter:Program Patients
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 6 6.00 63.72 10.62
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 5 5.00 44.15 8.83
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.00 31.56 10.52
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 5 5.00 97.54 19.51
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 5 5.00 123.50 24.70
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 12 21.50 1612.50 75.00
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 9.50 712.50 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 5.50 412.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 21.00 1165.50 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 125 220.50 16537.50 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 68 122.50 9187.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 39 62.50 4687.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 118 219.50 12182.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 57 86.00 6450.00 75.00
Subtotal (Total Children Is Unduplicated) 196 793.50 53383.22 67.28
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 2.00 100.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 109 392.00 26608.96 67.88
OCCT-97530HM-OT SESSION BY OT ASST 10 19.50 1059.24 54.32
PHY-97110-PT SESSION BY LICENSED PT 123 451.00 30613.88 67.88
PHY-97110HM-PT SESSION BY PT ASST 1 2.00 108.64 54.32
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 178 665.25 45159.24 67.88
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 5.50 298.76 54.32
SPL-92508-GROUP SPL SESSION PER CHILD 1 0.50 6.60 13.20
Subtotal (Total Children Is Unduplicated) 283 1537.75 103955.32 67.60
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Total 2331.25 157338.54 67.49
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Number of Children (Unduplicated) With at Least One Service 448
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Center 10
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 0 0.00 0.00 0.00
D 0 0.00 0.00 0.00
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
1336 2331.25 157338.54 0.00
Other 0 0.00 0.00 0.00
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Total 1336 2331.25 157338.54 0.00